Prospective Purchaser Questionnaire - The McGill & Hill Group

Saturday, September 4, 2010

Phone 704.424.9780 Fax 704.424.9786

www.mcgillhillgroup.com

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Buying and selling a practice requires both parties to share significant information with each other. In order to purchase a practice, a prospective purchaser requires a considerable amount of information about the practice. Likewise, a seller needs information about a potential purchaser, such as background and experience, to help ensure a successful sale. Therefore, our company requests that you complete this questionnaire and return it to our office. All responses will be kept confidential.

Prospective Purchaser

First Name:
Last Name:
Specialty:
Title:

Office Address:
Suite:
City, State Zip:
Office Phone:
Fax:

Home Address:
Apt:
City, State Zip:
Home Phone:
Fax:

Cell Phone:
Email:

Preferred Contact:	Confidential: Yes No
Best time to call:

Referred by:

Education

Degree:		Date:
School:
Specialty Training:		Date:
Specialty School:
Passed State Boards:		Date:
Passed Regional Boards:		Date:

Work Experience

Associate:		Number of Years:
Practice Owner:		Number of Years:
Other:		Number of Years:
Avg. mth. production:
Length of Transition Period you desire:
License #:		State:

Ideal Practice Information

Geographic Areas of Interest:
Size (gross receipts) of practice:	$ # of operatories:
Price range:	$
Would you relocate if practice meets your other requirements? Yes No

Personal Information

Age:
Marital Status:
Children & Their Ages:
Is spouse working?	Yes No
If so, what field?

Are there any judgments pending against you or any of your business interests? Yes No
If so, please explain:

Have you ever declared bankruptcy?	Yes No

To schedule a no-obligation telephone consultation with Mr. Hill, contact his assistant, Erica Flory at (704) 424-5626.

Phone 704.424.9780
Fax 704.424.9786